Patrick H. Conway, MD, MSc

At the Centers for Medicare and Medicaid Services (CMS), we are charged with implementing many of the major provisions of the Affordable Care Act (ACA). Major policies and programs aimed at transforming the way care is delivered and paid for, testing and scaling innovative delivery system reforms, and expanding the number of Americans with health insurance will now move forward. The healthcare system is moving from paying for volume to paying for value. Hospitals and clinicians will need to be able to manage and be accountable for populations of patients and improving health outcomes. In this article, we highlight 4 broad provisions of the ACA that are either already implemented or under development for implementation in 2014, and are anticipated to have widespread impact on our health system. The potential impacts of each provision on hospitals and hospitalists are outlined in Table 1.

EXPANSION OF INSURANCE COVERAGE

The central and perhaps most anticipated provision of the ACA is the expansion of insurance to the currently uninsured through the creation of state‐based health insurance exchanges. The exchanges are a competitive marketplace for purchasing private insurance products by individuals and small and large businesses. The individual mandate that accompanies the exchange provision requires that individuals purchase insurance. For those who cannot afford it, the government provides a subsidy. Any health plan that wishes to participate in an exchange marketplace must include at minimum a package of essential health benefits in each of their insurance products, which include benefits such as ambulatory care services, maternal and newborn services, and prescription drugs.[1] Importantly, health plans are required to implement quality improvement strategies and publicly report quality data. The ACA also requires the Secretary of Health and Human Services (HHS) to develop and administer a quality rating system and an enrollee satisfaction survey system, the results of which will be available to exchange consumers. All of these requirements will promote the delivery of high‐quality healthcare to millions of previously uninsured Americans.

Implementation of the exchanges in combination with the expansion of Medicaid is expected to provide insurance to approximately 30 million people who currently lack coverage. Prior to the Supreme Court ruling in June of 2012, states were required to expand Medicaid eligibility to a minimum of 133% of the federal poverty level. This expansion is subsidized 100% by the federal government through 2016, dropping to 90% by 2020. The Supreme Court ruled that the federal government could not require states to expand their Medicaid rolls, although it is expected that most states will do so given the generous federal subsidy and the significant cost to states, hospitals, and society to provide healthcare to the uninsured.

TRANSFORMATION OF HEALTHCARE DELIVERY

In addition to the expansion of insurance coverage, the ACA initiates a transformation in the way that healthcare will be delivered through the testing and implementation of innovative payment and care delivery models. The ACA authorized the creation of the Center for Medicare and Medicaid Innovation (CMMI, or The Innovation Center) within CMS. Payment and care delivery demonstrations or pilots that demonstrate a high quality of care at lower costs can be scaled up nationally at the discretion of the Secretary, rather than requiring authorization by Congress. The Innovation Center has already launched initiatives that test a variety of new models of care, all of which incentivize care coordination, provision of team‐based care, and use of data and quality metrics to drive systems‐based improvement. These programs include pilots that bundle payments to hospitals, physician group practices, and post‐acute care facilities for episodes of care across settings. This allows providers to innovate and redesign systems to deliver equivalent or higher quality of care at lower costs. Another CMMI model, called the comprehensive primary care initiative, involves CMS partnering with private insurers to provide payment to primary care practices for the delivery of chronic disease management and coordinated care to their entire population of patients, regardless of payer. Of great relevance to all hospitalists, CMMI and CMS, in partnership with other HHS agencies, launched the Partnership for Patients program in 2011. To date, approximately 4000 hospitals have signed on to the Partnership in a collective effort to significantly reduce hospital readmissions and hospital‐acquired conditions. Hospitalists are leading the charge related to Partnership for Patients in many hospitals. The Innovation Center is concurrently launching and rapidly evaluating current pilots, while considering what other new pilots might be needed to further test models aimed at the delivery of better healthcare and health outcomes at lower costs.

Perhaps the delivery system initiative that has received the most attention is the implementation of the Medicare Shared Savings Program (MSSP), or Accountable Care Organizations (ACO). Under the MSSP, ACOs are groups of providers (which may include hospitals) and suppliers of services who work together to coordinate care for the patients they serve. Participating ACOs must achieve performance benchmarks while lowering costs to share in the cost savings with CMS. Although this program is focused on Medicare fee‐for‐service (FFS) beneficiaries, it is expected that all patients will benefit from the infrastructure redesign and care coordination that is required under this program. The pioneer ACOs are large integrated health systems or other providers that have higher levels of shared risk in addition to shared savings. Hospitals that are a part of a participating ACO have greater financial incentives to work with their primary care and other outpatient providers to reduce readmissions and other adverse events and achieve quality benchmarks. With the degree of savings as well as financial risk that is on the table, it is possible that over time, hospitals and health systems may consolidate to capture a larger share of the market. Such a consequence could have a parallel effect on job opportunities and financial incentives and risk for hospitalists in local markets.

VALUE‐BASED PURCHASING

Improvement in the quality of care delivered to all patients is another central purpose of the Affordable Care Act. The law requires that the Secretary develop a National Quality Strategy that must be updated annually; the first version of this strategy was published in April of 2011.[2] The strategy identifies 3 aims for the nation: better healthcare for individuals, better health for populations and communities, and lower costs for all. One of the levers that CMS uses to achieve these 3 aims is value‐based purchasing (VBP). VBP is a way to link the National Quality Strategy with Medicare FFS payments on a national scale by adjusting payments based on performance. VBP rewards providers and health systems that deliver better outcomes in health and healthcare at lower cost to the beneficiaries and communities they serve, rather than rewarding them for the volume of services they provide. The ACA authorizes implementation of the Hospital Value‐Based Purchasing (HVBP) program as well as the Physician Value Modifier (PVM). The HVBP program began in 2011, and currently includes process, outcome, and patient experience quality metrics as well as a total cost metric, which includes 30 days postdischarge for beneficiaries admitted to the hospital. Hospitals are rewarded on either their improvement from baseline or achievement of a benchmark, whichever is higher.[3] The PVM program adjusts providers' Medicare FFS payments up or down beginning in 2015, based on quality metrics reported on care provided in 2013. In the first year of the program, groups of 100 or more physicians are eligible for the program, and are given a choice on metrics to report and whether to elect for quality tiering and the potential for payment adjustment[4]; by payment year 2017, all physicians must participate. To participate, physicians must report on quality metrics that they choose through the Physician Quality Reporting System (PQRS) or elect to have their quality assessed based on administrative claim measures. Measures currently in the PQRS program may not always be relevant for hospitalists; CMS is working to define and include metrics that would be most meaningful to hospitalists' scope of practice and is seeking comment on whether to allow hospital‐based physicians to align with and accept hospital quality measures to count as their performance metrics.

PATIENT‐CENTERED OUTCOMES RESEARCH

Building on the down payment on Comparative Effectiveness Research (CER) funded under the American Recovery and Reinvestment Act of 2009, the ACA authorized the creation of the Patient‐Centered Outcomes Research Institute (PCORI) and allocated funding for CER over 10 years. Rebranded as Patient‐Centered Outcomes Research (PCOR), CER has the potential to improve quality and reduce costs by identifying what works for different populations of patients (eg, children, elderly, patients with multiple chronic conditions, racial and ethnic minorities) in varied settings (eg, ambulatory, hospital, nursing home) under real‐world conditions. The PCORI governance board was created in 2010, and as required by law, developed a national agenda for patient‐centered outcomes research, which includes assessment of prevention, diagnosis, and treatment options; improving healthcare systems; communicating and disseminating research; addressing healthcare disparities; and accelerating PCOR and methodological research. The amount of funding available for research and PCOR infrastructure will ramp up over the next several years, eventually reaching approximately $500 million annually, with increasing funding opportunities for comparative research questions related to clinical and delivery system interventions using pragmatic, randomized, controlled trials; implementation science; and other novel research methodologies. Hospitalists have many roles within this realm, whether as researchers comparing delivery system or clinical interventions, as educators of students or healthcare professionals on the results of PCOR and their implications for practice, or as hospital leaders responsible for implementation of evidence‐based practices.[5]

CONCLUSION

The Affordable Care Act is a transformative piece of legislation, and our healthcare system is changing rapidly. Many of the ACA's provisions will change how care is delivered in the United States and will have a direct effect on practicing physicians, hospitals, and patients. Although CMS plays a major role in the implementation of the law, the government cannot be, and should not be, the primary force in transforming health care in this country. Through the provisions highlighted here as well as others, CMS can create a supportive environment, be a catalyst, and provide incentives for change; however, true transformation must occur on the front lines. For hospitalists, this means partnering with the hospital administration and other hospital personnel, local providers, and community organizations to drive systems‐based improvements that will ultimately achieve higher‐quality care at lower costs for all. It also calls for hospitalists to lead change in their local systems focused on better care, better health, and lower costs through improvement.

Disclosure

The views expressed in this manuscript represent the authors and not necessarily the policy or opinions of the Centers for Medicare and Medicaid Services.

At the Centers for Medicare and Medicaid Services (CMS), we are charged with implementing many of the major provisions of the Affordable Care Act (ACA). Major policies and programs aimed at transforming the way care is delivered and paid for, testing and scaling innovative delivery system reforms, and expanding the number of Americans with health insurance will now move forward. The healthcare system is moving from paying for volume to paying for value. Hospitals and clinicians will need to be able to manage and be accountable for populations of patients and improving health outcomes. In this article, we highlight 4 broad provisions of the ACA that are either already implemented or under development for implementation in 2014, and are anticipated to have widespread impact on our health system. The potential impacts of each provision on hospitals and hospitalists are outlined in Table 1.

EXPANSION OF INSURANCE COVERAGE

The central and perhaps most anticipated provision of the ACA is the expansion of insurance to the currently uninsured through the creation of state‐based health insurance exchanges. The exchanges are a competitive marketplace for purchasing private insurance products by individuals and small and large businesses. The individual mandate that accompanies the exchange provision requires that individuals purchase insurance. For those who cannot afford it, the government provides a subsidy. Any health plan that wishes to participate in an exchange marketplace must include at minimum a package of essential health benefits in each of their insurance products, which include benefits such as ambulatory care services, maternal and newborn services, and prescription drugs.[1] Importantly, health plans are required to implement quality improvement strategies and publicly report quality data. The ACA also requires the Secretary of Health and Human Services (HHS) to develop and administer a quality rating system and an enrollee satisfaction survey system, the results of which will be available to exchange consumers. All of these requirements will promote the delivery of high‐quality healthcare to millions of previously uninsured Americans.

Implementation of the exchanges in combination with the expansion of Medicaid is expected to provide insurance to approximately 30 million people who currently lack coverage. Prior to the Supreme Court ruling in June of 2012, states were required to expand Medicaid eligibility to a minimum of 133% of the federal poverty level. This expansion is subsidized 100% by the federal government through 2016, dropping to 90% by 2020. The Supreme Court ruled that the federal government could not require states to expand their Medicaid rolls, although it is expected that most states will do so given the generous federal subsidy and the significant cost to states, hospitals, and society to provide healthcare to the uninsured.

TRANSFORMATION OF HEALTHCARE DELIVERY

In addition to the expansion of insurance coverage, the ACA initiates a transformation in the way that healthcare will be delivered through the testing and implementation of innovative payment and care delivery models. The ACA authorized the creation of the Center for Medicare and Medicaid Innovation (CMMI, or The Innovation Center) within CMS. Payment and care delivery demonstrations or pilots that demonstrate a high quality of care at lower costs can be scaled up nationally at the discretion of the Secretary, rather than requiring authorization by Congress. The Innovation Center has already launched initiatives that test a variety of new models of care, all of which incentivize care coordination, provision of team‐based care, and use of data and quality metrics to drive systems‐based improvement. These programs include pilots that bundle payments to hospitals, physician group practices, and post‐acute care facilities for episodes of care across settings. This allows providers to innovate and redesign systems to deliver equivalent or higher quality of care at lower costs. Another CMMI model, called the comprehensive primary care initiative, involves CMS partnering with private insurers to provide payment to primary care practices for the delivery of chronic disease management and coordinated care to their entire population of patients, regardless of payer. Of great relevance to all hospitalists, CMMI and CMS, in partnership with other HHS agencies, launched the Partnership for Patients program in 2011. To date, approximately 4000 hospitals have signed on to the Partnership in a collective effort to significantly reduce hospital readmissions and hospital‐acquired conditions. Hospitalists are leading the charge related to Partnership for Patients in many hospitals. The Innovation Center is concurrently launching and rapidly evaluating current pilots, while considering what other new pilots might be needed to further test models aimed at the delivery of better healthcare and health outcomes at lower costs.

Perhaps the delivery system initiative that has received the most attention is the implementation of the Medicare Shared Savings Program (MSSP), or Accountable Care Organizations (ACO). Under the MSSP, ACOs are groups of providers (which may include hospitals) and suppliers of services who work together to coordinate care for the patients they serve. Participating ACOs must achieve performance benchmarks while lowering costs to share in the cost savings with CMS. Although this program is focused on Medicare fee‐for‐service (FFS) beneficiaries, it is expected that all patients will benefit from the infrastructure redesign and care coordination that is required under this program. The pioneer ACOs are large integrated health systems or other providers that have higher levels of shared risk in addition to shared savings. Hospitals that are a part of a participating ACO have greater financial incentives to work with their primary care and other outpatient providers to reduce readmissions and other adverse events and achieve quality benchmarks. With the degree of savings as well as financial risk that is on the table, it is possible that over time, hospitals and health systems may consolidate to capture a larger share of the market. Such a consequence could have a parallel effect on job opportunities and financial incentives and risk for hospitalists in local markets.

VALUE‐BASED PURCHASING

Improvement in the quality of care delivered to all patients is another central purpose of the Affordable Care Act. The law requires that the Secretary develop a National Quality Strategy that must be updated annually; the first version of this strategy was published in April of 2011.[2] The strategy identifies 3 aims for the nation: better healthcare for individuals, better health for populations and communities, and lower costs for all. One of the levers that CMS uses to achieve these 3 aims is value‐based purchasing (VBP). VBP is a way to link the National Quality Strategy with Medicare FFS payments on a national scale by adjusting payments based on performance. VBP rewards providers and health systems that deliver better outcomes in health and healthcare at lower cost to the beneficiaries and communities they serve, rather than rewarding them for the volume of services they provide. The ACA authorizes implementation of the Hospital Value‐Based Purchasing (HVBP) program as well as the Physician Value Modifier (PVM). The HVBP program began in 2011, and currently includes process, outcome, and patient experience quality metrics as well as a total cost metric, which includes 30 days postdischarge for beneficiaries admitted to the hospital. Hospitals are rewarded on either their improvement from baseline or achievement of a benchmark, whichever is higher.[3] The PVM program adjusts providers' Medicare FFS payments up or down beginning in 2015, based on quality metrics reported on care provided in 2013. In the first year of the program, groups of 100 or more physicians are eligible for the program, and are given a choice on metrics to report and whether to elect for quality tiering and the potential for payment adjustment[4]; by payment year 2017, all physicians must participate. To participate, physicians must report on quality metrics that they choose through the Physician Quality Reporting System (PQRS) or elect to have their quality assessed based on administrative claim measures. Measures currently in the PQRS program may not always be relevant for hospitalists; CMS is working to define and include metrics that would be most meaningful to hospitalists' scope of practice and is seeking comment on whether to allow hospital‐based physicians to align with and accept hospital quality measures to count as their performance metrics.

PATIENT‐CENTERED OUTCOMES RESEARCH

Building on the down payment on Comparative Effectiveness Research (CER) funded under the American Recovery and Reinvestment Act of 2009, the ACA authorized the creation of the Patient‐Centered Outcomes Research Institute (PCORI) and allocated funding for CER over 10 years. Rebranded as Patient‐Centered Outcomes Research (PCOR), CER has the potential to improve quality and reduce costs by identifying what works for different populations of patients (eg, children, elderly, patients with multiple chronic conditions, racial and ethnic minorities) in varied settings (eg, ambulatory, hospital, nursing home) under real‐world conditions. The PCORI governance board was created in 2010, and as required by law, developed a national agenda for patient‐centered outcomes research, which includes assessment of prevention, diagnosis, and treatment options; improving healthcare systems; communicating and disseminating research; addressing healthcare disparities; and accelerating PCOR and methodological research. The amount of funding available for research and PCOR infrastructure will ramp up over the next several years, eventually reaching approximately $500 million annually, with increasing funding opportunities for comparative research questions related to clinical and delivery system interventions using pragmatic, randomized, controlled trials; implementation science; and other novel research methodologies. Hospitalists have many roles within this realm, whether as researchers comparing delivery system or clinical interventions, as educators of students or healthcare professionals on the results of PCOR and their implications for practice, or as hospital leaders responsible for implementation of evidence‐based practices.[5]

CONCLUSION

The Affordable Care Act is a transformative piece of legislation, and our healthcare system is changing rapidly. Many of the ACA's provisions will change how care is delivered in the United States and will have a direct effect on practicing physicians, hospitals, and patients. Although CMS plays a major role in the implementation of the law, the government cannot be, and should not be, the primary force in transforming health care in this country. Through the provisions highlighted here as well as others, CMS can create a supportive environment, be a catalyst, and provide incentives for change; however, true transformation must occur on the front lines. For hospitalists, this means partnering with the hospital administration and other hospital personnel, local providers, and community organizations to drive systems‐based improvements that will ultimately achieve higher‐quality care at lower costs for all. It also calls for hospitalists to lead change in their local systems focused on better care, better health, and lower costs through improvement.

Disclosure

The views expressed in this manuscript represent the authors and not necessarily the policy or opinions of the Centers for Medicare and Medicaid Services.

At the Centers for Medicare and Medicaid Services (CMS), we are charged with implementing many of the major provisions of the Affordable Care Act (ACA). Major policies and programs aimed at transforming the way care is delivered and paid for, testing and scaling innovative delivery system reforms, and expanding the number of Americans with health insurance will now move forward. The healthcare system is moving from paying for volume to paying for value. Hospitals and clinicians will need to be able to manage and be accountable for populations of patients and improving health outcomes. In this article, we highlight 4 broad provisions of the ACA that are either already implemented or under development for implementation in 2014, and are anticipated to have widespread impact on our health system. The potential impacts of each provision on hospitals and hospitalists are outlined in Table 1.

EXPANSION OF INSURANCE COVERAGE

The central and perhaps most anticipated provision of the ACA is the expansion of insurance to the currently uninsured through the creation of state‐based health insurance exchanges. The exchanges are a competitive marketplace for purchasing private insurance products by individuals and small and large businesses. The individual mandate that accompanies the exchange provision requires that individuals purchase insurance. For those who cannot afford it, the government provides a subsidy. Any health plan that wishes to participate in an exchange marketplace must include at minimum a package of essential health benefits in each of their insurance products, which include benefits such as ambulatory care services, maternal and newborn services, and prescription drugs.[1] Importantly, health plans are required to implement quality improvement strategies and publicly report quality data. The ACA also requires the Secretary of Health and Human Services (HHS) to develop and administer a quality rating system and an enrollee satisfaction survey system, the results of which will be available to exchange consumers. All of these requirements will promote the delivery of high‐quality healthcare to millions of previously uninsured Americans.

Implementation of the exchanges in combination with the expansion of Medicaid is expected to provide insurance to approximately 30 million people who currently lack coverage. Prior to the Supreme Court ruling in June of 2012, states were required to expand Medicaid eligibility to a minimum of 133% of the federal poverty level. This expansion is subsidized 100% by the federal government through 2016, dropping to 90% by 2020. The Supreme Court ruled that the federal government could not require states to expand their Medicaid rolls, although it is expected that most states will do so given the generous federal subsidy and the significant cost to states, hospitals, and society to provide healthcare to the uninsured.

TRANSFORMATION OF HEALTHCARE DELIVERY

In addition to the expansion of insurance coverage, the ACA initiates a transformation in the way that healthcare will be delivered through the testing and implementation of innovative payment and care delivery models. The ACA authorized the creation of the Center for Medicare and Medicaid Innovation (CMMI, or The Innovation Center) within CMS. Payment and care delivery demonstrations or pilots that demonstrate a high quality of care at lower costs can be scaled up nationally at the discretion of the Secretary, rather than requiring authorization by Congress. The Innovation Center has already launched initiatives that test a variety of new models of care, all of which incentivize care coordination, provision of team‐based care, and use of data and quality metrics to drive systems‐based improvement. These programs include pilots that bundle payments to hospitals, physician group practices, and post‐acute care facilities for episodes of care across settings. This allows providers to innovate and redesign systems to deliver equivalent or higher quality of care at lower costs. Another CMMI model, called the comprehensive primary care initiative, involves CMS partnering with private insurers to provide payment to primary care practices for the delivery of chronic disease management and coordinated care to their entire population of patients, regardless of payer. Of great relevance to all hospitalists, CMMI and CMS, in partnership with other HHS agencies, launched the Partnership for Patients program in 2011. To date, approximately 4000 hospitals have signed on to the Partnership in a collective effort to significantly reduce hospital readmissions and hospital‐acquired conditions. Hospitalists are leading the charge related to Partnership for Patients in many hospitals. The Innovation Center is concurrently launching and rapidly evaluating current pilots, while considering what other new pilots might be needed to further test models aimed at the delivery of better healthcare and health outcomes at lower costs.

Perhaps the delivery system initiative that has received the most attention is the implementation of the Medicare Shared Savings Program (MSSP), or Accountable Care Organizations (ACO). Under the MSSP, ACOs are groups of providers (which may include hospitals) and suppliers of services who work together to coordinate care for the patients they serve. Participating ACOs must achieve performance benchmarks while lowering costs to share in the cost savings with CMS. Although this program is focused on Medicare fee‐for‐service (FFS) beneficiaries, it is expected that all patients will benefit from the infrastructure redesign and care coordination that is required under this program. The pioneer ACOs are large integrated health systems or other providers that have higher levels of shared risk in addition to shared savings. Hospitals that are a part of a participating ACO have greater financial incentives to work with their primary care and other outpatient providers to reduce readmissions and other adverse events and achieve quality benchmarks. With the degree of savings as well as financial risk that is on the table, it is possible that over time, hospitals and health systems may consolidate to capture a larger share of the market. Such a consequence could have a parallel effect on job opportunities and financial incentives and risk for hospitalists in local markets.

VALUE‐BASED PURCHASING

Improvement in the quality of care delivered to all patients is another central purpose of the Affordable Care Act. The law requires that the Secretary develop a National Quality Strategy that must be updated annually; the first version of this strategy was published in April of 2011.[2] The strategy identifies 3 aims for the nation: better healthcare for individuals, better health for populations and communities, and lower costs for all. One of the levers that CMS uses to achieve these 3 aims is value‐based purchasing (VBP). VBP is a way to link the National Quality Strategy with Medicare FFS payments on a national scale by adjusting payments based on performance. VBP rewards providers and health systems that deliver better outcomes in health and healthcare at lower cost to the beneficiaries and communities they serve, rather than rewarding them for the volume of services they provide. The ACA authorizes implementation of the Hospital Value‐Based Purchasing (HVBP) program as well as the Physician Value Modifier (PVM). The HVBP program began in 2011, and currently includes process, outcome, and patient experience quality metrics as well as a total cost metric, which includes 30 days postdischarge for beneficiaries admitted to the hospital. Hospitals are rewarded on either their improvement from baseline or achievement of a benchmark, whichever is higher.[3] The PVM program adjusts providers' Medicare FFS payments up or down beginning in 2015, based on quality metrics reported on care provided in 2013. In the first year of the program, groups of 100 or more physicians are eligible for the program, and are given a choice on metrics to report and whether to elect for quality tiering and the potential for payment adjustment[4]; by payment year 2017, all physicians must participate. To participate, physicians must report on quality metrics that they choose through the Physician Quality Reporting System (PQRS) or elect to have their quality assessed based on administrative claim measures. Measures currently in the PQRS program may not always be relevant for hospitalists; CMS is working to define and include metrics that would be most meaningful to hospitalists' scope of practice and is seeking comment on whether to allow hospital‐based physicians to align with and accept hospital quality measures to count as their performance metrics.

PATIENT‐CENTERED OUTCOMES RESEARCH

Building on the down payment on Comparative Effectiveness Research (CER) funded under the American Recovery and Reinvestment Act of 2009, the ACA authorized the creation of the Patient‐Centered Outcomes Research Institute (PCORI) and allocated funding for CER over 10 years. Rebranded as Patient‐Centered Outcomes Research (PCOR), CER has the potential to improve quality and reduce costs by identifying what works for different populations of patients (eg, children, elderly, patients with multiple chronic conditions, racial and ethnic minorities) in varied settings (eg, ambulatory, hospital, nursing home) under real‐world conditions. The PCORI governance board was created in 2010, and as required by law, developed a national agenda for patient‐centered outcomes research, which includes assessment of prevention, diagnosis, and treatment options; improving healthcare systems; communicating and disseminating research; addressing healthcare disparities; and accelerating PCOR and methodological research. The amount of funding available for research and PCOR infrastructure will ramp up over the next several years, eventually reaching approximately $500 million annually, with increasing funding opportunities for comparative research questions related to clinical and delivery system interventions using pragmatic, randomized, controlled trials; implementation science; and other novel research methodologies. Hospitalists have many roles within this realm, whether as researchers comparing delivery system or clinical interventions, as educators of students or healthcare professionals on the results of PCOR and their implications for practice, or as hospital leaders responsible for implementation of evidence‐based practices.[5]

CONCLUSION

The Affordable Care Act is a transformative piece of legislation, and our healthcare system is changing rapidly. Many of the ACA's provisions will change how care is delivered in the United States and will have a direct effect on practicing physicians, hospitals, and patients. Although CMS plays a major role in the implementation of the law, the government cannot be, and should not be, the primary force in transforming health care in this country. Through the provisions highlighted here as well as others, CMS can create a supportive environment, be a catalyst, and provide incentives for change; however, true transformation must occur on the front lines. For hospitalists, this means partnering with the hospital administration and other hospital personnel, local providers, and community organizations to drive systems‐based improvements that will ultimately achieve higher‐quality care at lower costs for all. It also calls for hospitalists to lead change in their local systems focused on better care, better health, and lower costs through improvement.

Disclosure

The views expressed in this manuscript represent the authors and not necessarily the policy or opinions of the Centers for Medicare and Medicaid Services.

The past several years have seen a dramatic increase in the percentage of patients cared for by hospitalists, yet an emerging body of literature examining the association between care given by hospitalists and performance on a number of process measures has shown mixed results. Hospitalists do not appear to provide higher quality of care for pneumonia,1, 2 while results in heart failure are mixed.35 Each of these studies was conducted at a single site, and examined patient‐level effects. More recently, Vasilevskis et al6 assessed the association between the intensity of hospitalist use (measured as the percentage of patients admitted by hospitalists) and performance on process measures. In a cohort of 208 California hospitals, they found a significant improvement in performance on process measures in patients with acute myocardial infarction, heart failure, and pneumonia with increasing percentages of patients admitted by hospitalists.6

To date, no study has examined the association between the use of hospitalists and the publicly reported 30‐day mortality and readmission measures. Specifically, the Centers for Medicare and Medicaid Services (CMS) have developed and now publicly report risk‐standardized 30‐day mortality (RSMR) and readmission rates (RSRR) for Medicare patients hospitalized for 3 common and costly conditionsacute myocardial infarction (AMI), heart failure (HF), and pneumonia.7 Performance on these hospital‐based quality measures varies widely, and vary by hospital volume, ownership status, teaching status, and nurse staffing levels.813 However, even accounting for these characteristics leaves much of the variation in outcomes unexplained. We hypothesized that the presence of hospitalists within a hospital would be associated with higher performance on 30‐day mortality and 30‐day readmission measures for AMI, HF, and pneumonia. We further hypothesized that for hospitals using hospitalists, there would be a positive correlation between increasing percentage of patients admitted by hospitalists and performance on outcome measures. To test these hypotheses, we conducted a national survey of hospitalist leaders, linking data from survey responses to data on publicly reported outcome measures for AMI, HF, and pneumonia.

MATERIALS AND METHODS

RESULTS

DISCUSSION

In this national survey of hospitals, we did not find a significant association between the use of hospitalists and hospitals' performance on 30‐day mortality or readmissions measures for AMI, HF, or pneumonia. While there was a statistically lower 30‐day risk‐standardized readmission rate measure for the heart failure measure among hospitals that use hospitalists, the effect size was small. The survey response rate of 40% is comparable to other surveys of physicians and other healthcare personnel, however, there were no significant differences between responders and nonresponders, so the potential for response bias, while present, is small.

Contrary to the findings of a recent study,21 we did not find a higher readmission rate for any of the 3 conditions in hospitals with hospitalist programs. One advantage of our study is the use of more robust risk‐adjustment methods. Our study used NQF‐endorsed risk‐standardized measures of readmission, which capture readmissions to any hospital for common, high priority conditions where the impact of care coordination and discontinuity of care are paramount. The models use administrative claims data, but have been validated by medical record data. Another advantage is that our study focused on a time period when hospital readmissions were a standard quality benchmark and increasing priority for hospitals, hospitalists, and community‐based care delivery systems. While our study is not able to discern whether patients had primary care physicians or the reason for admission to a hospitalist's care, our data do suggest that hospitalists continue to care for a large percentage of hospitalized patients. Moreover, increasing the proportion of patients being admitted to hospitalists did not affect the risk for readmission, providing perhaps reassuring evidence (or lack of proof) for a direct association between use of hospitalist systems and higher risk for readmission.

While hospitals with hospitalists clearly did not have better mortality or readmission rates, an alternate viewpoint might hold that, despite concerns that hospitalists negatively impact care continuity, our data do not demonstrate an association between readmission rates and use of hospitalist services. It is possible that hospitals that have hospitalists may have more ability to invest in hospital‐based systems of care,22 an association which may incorporate any hospitalist effect, but our results were robust even after testing whether adjustment for hospital factors (such as profit status, size) affected our results.

It is also possible that secular trends in hospitals or hospitalist systems affected our results. A handful of single‐site studies carried out soon after the hospitalist model's earliest descriptions found a reduction in mortality and readmission rates with the implementation of a hospitalist program.2325 Alternatively, it may be that there has been a dilution of the effect of hospitalists as often occurs when any new innovation is spread from early adopter sites to routine practice. Consistent with other multicenter studies from recent eras,21, 26 our article's findings do not demonstrate an association between hospitalists and improved outcomes. Unlike other multicenter studies, we had access to disease‐specific risk‐adjustment methodologies, which may partially account for referral biases related to patient‐specific measures of acute or chronic illness severity.

Changes in the hospitalist effect over time have a number of explanations, some of which are relevant to our study. Recent evidence suggests that complex organizational characteristics, such as organizational values and goals, may contribute to performance on 30‐day mortality for AMI rather than specific processes and protocols27; intense focus on AMI as a quality improvement target is emblematic of a number of national initiatives that may have affected our results. Interestingly, hospitalist systems have changed over time as well. Early in the hospitalist movement, hospitalist systems were implemented largely at the behest of hospitals trying to reduce costs. In recent years, however, hospitalist systems are at least as frequently being implemented because outpatient‐based physicians or surgeons request hospitalists; hospitalists have been focused on care of uncoveredpatients, since the model's earliest description. In addition, some hospitals invest in hospitalist programs based on perceived ability of hospitalists to improve quality and achieve better patient outcomes in an era of payment increasingly being linked to quality of care metrics.

Our study has several limitations, six of which are noted here. First, while the hospitalist model has been widely embraced in the adult medicine field, in the absence of board certification, there is no gold standard definition of a hospitalist. It is therefore possible that some respondents may have represented groups that were identified incorrectly as hospitalists. Second, the data for the primary independent variable of interest was based upon self‐report and, therefore, subject to recall bias and potential misclassification of results. Respondents were not aware of our hypothesis, so the bias should not have been in one particular direction. Third, the data for the outcome variables are from 2008. They may, therefore, not reflect organizational enhancements related to use of hospitalists that are in process, and take years to yield downstream improvements on performance metrics. In addition, of the 429 hospitals that have hospitalist programs, 46 programs were initiated after 2008. While national performance on the 6 outcome variables has been relatively static over time,7 any significant change in hospital performance on these metrics since 2008 could suggest an overestimation or underestimation of the effect of hospitalist programs on patient outcomes. Fourth, we were not able to adjust for additional hospital or health system level characteristics that may be associated with hospitalist use or patient outcomes. Fifth, our regression models had significant collinearity, in that the presence of hospitalists was correlated with each of the covariates. However, this finding would indicate that our estimates may be overly conservative and could have contributed to our nonsignificant findings. Finally, outcomes for 2 of the 3 clinical conditions measured are ones for which hospitalists may less frequently provide care: acute myocardial infarction and heart failure. Outcome measures more relevant for hospitalists may be all‐condition, all‐cause, 30‐day mortality and readmission.

This work adds to the growing body of literature examining the impact of hospitalists on quality of care. To our knowledge, it is the first study to assess the association between hospitalist use and performance on outcome metrics at a national level. While our findings suggest that use of hospitalists alone may not lead to improved performance on outcome measures, a parallel body of research is emerging implicating broader system and organizational factors as key to high performance on outcome measures. It is likely that multiple factors contribute to performance on outcome measures, including type and mix of hospital personnel, patient care processes and workflow, and system level attributes. Comparative effectiveness and implementation research that assess the contextual factors and interventions that lead to successful system improvement and better performance is increasingly needed. It is unlikely that a single factor, such as hospitalist use, will significantly impact 30‐day mortality or readmission and, therefore, multifactorial interventions are likely required. In addition, hospitalist use is a complex intervention as the structure, processes, training, experience, role in the hospital system, and other factors (including quality of hospitalists or the hospitalist program) vary across programs. Rather than focusing on the volume of care delivered by hospitalists, hospitals will likely need to support hospital medicine programs that have the time and expertise to devote to improving the quality and value of care delivered across the hospital system. This study highlights that interventions leading to improvement on core outcome measures are more complex than simply having a hospital medicine program.

The past several years have seen a dramatic increase in the percentage of patients cared for by hospitalists, yet an emerging body of literature examining the association between care given by hospitalists and performance on a number of process measures has shown mixed results. Hospitalists do not appear to provide higher quality of care for pneumonia,1, 2 while results in heart failure are mixed.35 Each of these studies was conducted at a single site, and examined patient‐level effects. More recently, Vasilevskis et al6 assessed the association between the intensity of hospitalist use (measured as the percentage of patients admitted by hospitalists) and performance on process measures. In a cohort of 208 California hospitals, they found a significant improvement in performance on process measures in patients with acute myocardial infarction, heart failure, and pneumonia with increasing percentages of patients admitted by hospitalists.6

To date, no study has examined the association between the use of hospitalists and the publicly reported 30‐day mortality and readmission measures. Specifically, the Centers for Medicare and Medicaid Services (CMS) have developed and now publicly report risk‐standardized 30‐day mortality (RSMR) and readmission rates (RSRR) for Medicare patients hospitalized for 3 common and costly conditionsacute myocardial infarction (AMI), heart failure (HF), and pneumonia.7 Performance on these hospital‐based quality measures varies widely, and vary by hospital volume, ownership status, teaching status, and nurse staffing levels.813 However, even accounting for these characteristics leaves much of the variation in outcomes unexplained. We hypothesized that the presence of hospitalists within a hospital would be associated with higher performance on 30‐day mortality and 30‐day readmission measures for AMI, HF, and pneumonia. We further hypothesized that for hospitals using hospitalists, there would be a positive correlation between increasing percentage of patients admitted by hospitalists and performance on outcome measures. To test these hypotheses, we conducted a national survey of hospitalist leaders, linking data from survey responses to data on publicly reported outcome measures for AMI, HF, and pneumonia.

MATERIALS AND METHODS

RESULTS

DISCUSSION

In this national survey of hospitals, we did not find a significant association between the use of hospitalists and hospitals' performance on 30‐day mortality or readmissions measures for AMI, HF, or pneumonia. While there was a statistically lower 30‐day risk‐standardized readmission rate measure for the heart failure measure among hospitals that use hospitalists, the effect size was small. The survey response rate of 40% is comparable to other surveys of physicians and other healthcare personnel, however, there were no significant differences between responders and nonresponders, so the potential for response bias, while present, is small.

Contrary to the findings of a recent study,21 we did not find a higher readmission rate for any of the 3 conditions in hospitals with hospitalist programs. One advantage of our study is the use of more robust risk‐adjustment methods. Our study used NQF‐endorsed risk‐standardized measures of readmission, which capture readmissions to any hospital for common, high priority conditions where the impact of care coordination and discontinuity of care are paramount. The models use administrative claims data, but have been validated by medical record data. Another advantage is that our study focused on a time period when hospital readmissions were a standard quality benchmark and increasing priority for hospitals, hospitalists, and community‐based care delivery systems. While our study is not able to discern whether patients had primary care physicians or the reason for admission to a hospitalist's care, our data do suggest that hospitalists continue to care for a large percentage of hospitalized patients. Moreover, increasing the proportion of patients being admitted to hospitalists did not affect the risk for readmission, providing perhaps reassuring evidence (or lack of proof) for a direct association between use of hospitalist systems and higher risk for readmission.

While hospitals with hospitalists clearly did not have better mortality or readmission rates, an alternate viewpoint might hold that, despite concerns that hospitalists negatively impact care continuity, our data do not demonstrate an association between readmission rates and use of hospitalist services. It is possible that hospitals that have hospitalists may have more ability to invest in hospital‐based systems of care,22 an association which may incorporate any hospitalist effect, but our results were robust even after testing whether adjustment for hospital factors (such as profit status, size) affected our results.

It is also possible that secular trends in hospitals or hospitalist systems affected our results. A handful of single‐site studies carried out soon after the hospitalist model's earliest descriptions found a reduction in mortality and readmission rates with the implementation of a hospitalist program.2325 Alternatively, it may be that there has been a dilution of the effect of hospitalists as often occurs when any new innovation is spread from early adopter sites to routine practice. Consistent with other multicenter studies from recent eras,21, 26 our article's findings do not demonstrate an association between hospitalists and improved outcomes. Unlike other multicenter studies, we had access to disease‐specific risk‐adjustment methodologies, which may partially account for referral biases related to patient‐specific measures of acute or chronic illness severity.

Changes in the hospitalist effect over time have a number of explanations, some of which are relevant to our study. Recent evidence suggests that complex organizational characteristics, such as organizational values and goals, may contribute to performance on 30‐day mortality for AMI rather than specific processes and protocols27; intense focus on AMI as a quality improvement target is emblematic of a number of national initiatives that may have affected our results. Interestingly, hospitalist systems have changed over time as well. Early in the hospitalist movement, hospitalist systems were implemented largely at the behest of hospitals trying to reduce costs. In recent years, however, hospitalist systems are at least as frequently being implemented because outpatient‐based physicians or surgeons request hospitalists; hospitalists have been focused on care of uncoveredpatients, since the model's earliest description. In addition, some hospitals invest in hospitalist programs based on perceived ability of hospitalists to improve quality and achieve better patient outcomes in an era of payment increasingly being linked to quality of care metrics.

Our study has several limitations, six of which are noted here. First, while the hospitalist model has been widely embraced in the adult medicine field, in the absence of board certification, there is no gold standard definition of a hospitalist. It is therefore possible that some respondents may have represented groups that were identified incorrectly as hospitalists. Second, the data for the primary independent variable of interest was based upon self‐report and, therefore, subject to recall bias and potential misclassification of results. Respondents were not aware of our hypothesis, so the bias should not have been in one particular direction. Third, the data for the outcome variables are from 2008. They may, therefore, not reflect organizational enhancements related to use of hospitalists that are in process, and take years to yield downstream improvements on performance metrics. In addition, of the 429 hospitals that have hospitalist programs, 46 programs were initiated after 2008. While national performance on the 6 outcome variables has been relatively static over time,7 any significant change in hospital performance on these metrics since 2008 could suggest an overestimation or underestimation of the effect of hospitalist programs on patient outcomes. Fourth, we were not able to adjust for additional hospital or health system level characteristics that may be associated with hospitalist use or patient outcomes. Fifth, our regression models had significant collinearity, in that the presence of hospitalists was correlated with each of the covariates. However, this finding would indicate that our estimates may be overly conservative and could have contributed to our nonsignificant findings. Finally, outcomes for 2 of the 3 clinical conditions measured are ones for which hospitalists may less frequently provide care: acute myocardial infarction and heart failure. Outcome measures more relevant for hospitalists may be all‐condition, all‐cause, 30‐day mortality and readmission.

This work adds to the growing body of literature examining the impact of hospitalists on quality of care. To our knowledge, it is the first study to assess the association between hospitalist use and performance on outcome metrics at a national level. While our findings suggest that use of hospitalists alone may not lead to improved performance on outcome measures, a parallel body of research is emerging implicating broader system and organizational factors as key to high performance on outcome measures. It is likely that multiple factors contribute to performance on outcome measures, including type and mix of hospital personnel, patient care processes and workflow, and system level attributes. Comparative effectiveness and implementation research that assess the contextual factors and interventions that lead to successful system improvement and better performance is increasingly needed. It is unlikely that a single factor, such as hospitalist use, will significantly impact 30‐day mortality or readmission and, therefore, multifactorial interventions are likely required. In addition, hospitalist use is a complex intervention as the structure, processes, training, experience, role in the hospital system, and other factors (including quality of hospitalists or the hospitalist program) vary across programs. Rather than focusing on the volume of care delivered by hospitalists, hospitals will likely need to support hospital medicine programs that have the time and expertise to devote to improving the quality and value of care delivered across the hospital system. This study highlights that interventions leading to improvement on core outcome measures are more complex than simply having a hospital medicine program.

The past several years have seen a dramatic increase in the percentage of patients cared for by hospitalists, yet an emerging body of literature examining the association between care given by hospitalists and performance on a number of process measures has shown mixed results. Hospitalists do not appear to provide higher quality of care for pneumonia,1, 2 while results in heart failure are mixed.35 Each of these studies was conducted at a single site, and examined patient‐level effects. More recently, Vasilevskis et al6 assessed the association between the intensity of hospitalist use (measured as the percentage of patients admitted by hospitalists) and performance on process measures. In a cohort of 208 California hospitals, they found a significant improvement in performance on process measures in patients with acute myocardial infarction, heart failure, and pneumonia with increasing percentages of patients admitted by hospitalists.6

To date, no study has examined the association between the use of hospitalists and the publicly reported 30‐day mortality and readmission measures. Specifically, the Centers for Medicare and Medicaid Services (CMS) have developed and now publicly report risk‐standardized 30‐day mortality (RSMR) and readmission rates (RSRR) for Medicare patients hospitalized for 3 common and costly conditionsacute myocardial infarction (AMI), heart failure (HF), and pneumonia.7 Performance on these hospital‐based quality measures varies widely, and vary by hospital volume, ownership status, teaching status, and nurse staffing levels.813 However, even accounting for these characteristics leaves much of the variation in outcomes unexplained. We hypothesized that the presence of hospitalists within a hospital would be associated with higher performance on 30‐day mortality and 30‐day readmission measures for AMI, HF, and pneumonia. We further hypothesized that for hospitals using hospitalists, there would be a positive correlation between increasing percentage of patients admitted by hospitalists and performance on outcome measures. To test these hypotheses, we conducted a national survey of hospitalist leaders, linking data from survey responses to data on publicly reported outcome measures for AMI, HF, and pneumonia.

MATERIALS AND METHODS

RESULTS

DISCUSSION

In this national survey of hospitals, we did not find a significant association between the use of hospitalists and hospitals' performance on 30‐day mortality or readmissions measures for AMI, HF, or pneumonia. While there was a statistically lower 30‐day risk‐standardized readmission rate measure for the heart failure measure among hospitals that use hospitalists, the effect size was small. The survey response rate of 40% is comparable to other surveys of physicians and other healthcare personnel, however, there were no significant differences between responders and nonresponders, so the potential for response bias, while present, is small.

Contrary to the findings of a recent study,21 we did not find a higher readmission rate for any of the 3 conditions in hospitals with hospitalist programs. One advantage of our study is the use of more robust risk‐adjustment methods. Our study used NQF‐endorsed risk‐standardized measures of readmission, which capture readmissions to any hospital for common, high priority conditions where the impact of care coordination and discontinuity of care are paramount. The models use administrative claims data, but have been validated by medical record data. Another advantage is that our study focused on a time period when hospital readmissions were a standard quality benchmark and increasing priority for hospitals, hospitalists, and community‐based care delivery systems. While our study is not able to discern whether patients had primary care physicians or the reason for admission to a hospitalist's care, our data do suggest that hospitalists continue to care for a large percentage of hospitalized patients. Moreover, increasing the proportion of patients being admitted to hospitalists did not affect the risk for readmission, providing perhaps reassuring evidence (or lack of proof) for a direct association between use of hospitalist systems and higher risk for readmission.

While hospitals with hospitalists clearly did not have better mortality or readmission rates, an alternate viewpoint might hold that, despite concerns that hospitalists negatively impact care continuity, our data do not demonstrate an association between readmission rates and use of hospitalist services. It is possible that hospitals that have hospitalists may have more ability to invest in hospital‐based systems of care,22 an association which may incorporate any hospitalist effect, but our results were robust even after testing whether adjustment for hospital factors (such as profit status, size) affected our results.

It is also possible that secular trends in hospitals or hospitalist systems affected our results. A handful of single‐site studies carried out soon after the hospitalist model's earliest descriptions found a reduction in mortality and readmission rates with the implementation of a hospitalist program.2325 Alternatively, it may be that there has been a dilution of the effect of hospitalists as often occurs when any new innovation is spread from early adopter sites to routine practice. Consistent with other multicenter studies from recent eras,21, 26 our article's findings do not demonstrate an association between hospitalists and improved outcomes. Unlike other multicenter studies, we had access to disease‐specific risk‐adjustment methodologies, which may partially account for referral biases related to patient‐specific measures of acute or chronic illness severity.

Changes in the hospitalist effect over time have a number of explanations, some of which are relevant to our study. Recent evidence suggests that complex organizational characteristics, such as organizational values and goals, may contribute to performance on 30‐day mortality for AMI rather than specific processes and protocols27; intense focus on AMI as a quality improvement target is emblematic of a number of national initiatives that may have affected our results. Interestingly, hospitalist systems have changed over time as well. Early in the hospitalist movement, hospitalist systems were implemented largely at the behest of hospitals trying to reduce costs. In recent years, however, hospitalist systems are at least as frequently being implemented because outpatient‐based physicians or surgeons request hospitalists; hospitalists have been focused on care of uncoveredpatients, since the model's earliest description. In addition, some hospitals invest in hospitalist programs based on perceived ability of hospitalists to improve quality and achieve better patient outcomes in an era of payment increasingly being linked to quality of care metrics.

Our study has several limitations, six of which are noted here. First, while the hospitalist model has been widely embraced in the adult medicine field, in the absence of board certification, there is no gold standard definition of a hospitalist. It is therefore possible that some respondents may have represented groups that were identified incorrectly as hospitalists. Second, the data for the primary independent variable of interest was based upon self‐report and, therefore, subject to recall bias and potential misclassification of results. Respondents were not aware of our hypothesis, so the bias should not have been in one particular direction. Third, the data for the outcome variables are from 2008. They may, therefore, not reflect organizational enhancements related to use of hospitalists that are in process, and take years to yield downstream improvements on performance metrics. In addition, of the 429 hospitals that have hospitalist programs, 46 programs were initiated after 2008. While national performance on the 6 outcome variables has been relatively static over time,7 any significant change in hospital performance on these metrics since 2008 could suggest an overestimation or underestimation of the effect of hospitalist programs on patient outcomes. Fourth, we were not able to adjust for additional hospital or health system level characteristics that may be associated with hospitalist use or patient outcomes. Fifth, our regression models had significant collinearity, in that the presence of hospitalists was correlated with each of the covariates. However, this finding would indicate that our estimates may be overly conservative and could have contributed to our nonsignificant findings. Finally, outcomes for 2 of the 3 clinical conditions measured are ones for which hospitalists may less frequently provide care: acute myocardial infarction and heart failure. Outcome measures more relevant for hospitalists may be all‐condition, all‐cause, 30‐day mortality and readmission.

This work adds to the growing body of literature examining the impact of hospitalists on quality of care. To our knowledge, it is the first study to assess the association between hospitalist use and performance on outcome metrics at a national level. While our findings suggest that use of hospitalists alone may not lead to improved performance on outcome measures, a parallel body of research is emerging implicating broader system and organizational factors as key to high performance on outcome measures. It is likely that multiple factors contribute to performance on outcome measures, including type and mix of hospital personnel, patient care processes and workflow, and system level attributes. Comparative effectiveness and implementation research that assess the contextual factors and interventions that lead to successful system improvement and better performance is increasingly needed. It is unlikely that a single factor, such as hospitalist use, will significantly impact 30‐day mortality or readmission and, therefore, multifactorial interventions are likely required. In addition, hospitalist use is a complex intervention as the structure, processes, training, experience, role in the hospital system, and other factors (including quality of hospitalists or the hospitalist program) vary across programs. Rather than focusing on the volume of care delivered by hospitalists, hospitals will likely need to support hospital medicine programs that have the time and expertise to devote to improving the quality and value of care delivered across the hospital system. This study highlights that interventions leading to improvement on core outcome measures are more complex than simply having a hospital medicine program.

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

In the United States, general medical inpatient care is increasingly provided by hospital‐based physicians, also called hospitalists.1 The field of pediatrics is no exception, and by 2005 there were an estimated 1000 pediatric hospitalists in the workforce.2 Current numbers are likely to be greater than 2500, as the need for pediatric hospitalists has grown considerably.

At the same time, the quality of care delivered by the United States health system has come under increased scrutiny. In 2001, the Institute of Medicine, in its report on the quality of healthcare in America, concluded that between the care we have and what we could have lies not just a gap but a chasm.3 Meanwhile, the cost of healthcare delivery continues to increase. The pressure to deliver cost‐effective, high quality care is among the more important forces driving the proliferation of hospitalists.4

Over the last decade, data supporting the role of hospitalists in improving quality of care for adult patients has continued to accumulate.58 A 2007 retrospective cohort study by Lindenaur et al.7 included nearly 77,000 adult patients and found small reductions in length of stay without adverse effects on mortality or readmission rates, and a 2009 systematic review by Peterson6 included 33 studies and concluded that in general inpatient care of general medical patients by hospitalist physicians leads to decreased hospital cost and length of stay. A 2002 study by Meltzer et al.8 is also interesting, suggesting that improvements in costs and short‐term mortality are related to the disease‐specific experience of hospitalists.

Similar data for pediatric hospitalists has been slower to emerge. A systematic review of the literature by Landrigan et al., which included studies through 2004, concluded that [R]esearch suggests that pediatric hospitalists decrease costs and length of stay . The quality of care in pediatric hospitalist systems is unclear, because rigorous metrics to evaluate quality are lacking.9 Since the publication of that review, there have been multiple studies which have sought to evaluate the quality of pediatric hospitalist systems. This review was undertaken to synthesize this new information, and to determine the effect of pediatric hospitalist systems on quality of care.

METHODS

A review of the available English language literature on the Medline database was undertaken in November of 2010 to answer the question, What are the differences in quality of care and outcomes of inpatient medical care provided by hospitalists versus non‐hospitalists in the pediatric population? Care metrics of interest were categorized according to the Society of Hospital Medicine's recommendations for measuring hospital performance.10

Search terms used (with additional medical subject headings [MeSH] terms in parenthesis) were hospital medicine (hospitalist), pediatrics (child health, child welfare), cost (cost and cost analysis), quality (quality indicators, healthcare), outcomes (outcome assessment, healthcare; outcomes and process assessment, healthcare); volume, patient satisfaction, length of stay, productivity (efficiency), provider satisfaction (attitude of health personnel, job satisfaction), mortality, and readmission rate (patient readmission). The citing articles search tool was used to identify other articles that potentially could meet criteria. Finally, references cited in the selected articles, as well as in excluded literature reviews, were searched for additional articles.

Articles were deemed eligible if they were published in a peer‐reviewed journal, if they had a comparative experimental design for hospitalists versus non‐hospitalists, and if they dealt exclusively with pediatric hospitalists. Noncomparative studies were excluded, as were studies that pertained to settings besides that of an inpatient pediatrics ward, such as pediatric intensive care units or emergency rooms. The search algorithm is diagrammed in Figure 1.

Figure 1

The selected articles were reviewed for the relevant outcome measures. The quality of each article was assessed using the Oxford Centre for Evidence‐Based Medicine levels of evidence,11 a widely accepted standard for critical analysis of studies. Levels of evidence are assigned to studies, from 1a (systematic reviews of randomized controlled trials) to 5 (expert opinion only). Well‐conducted prospective cohort studies receive a rating of 2c; those with wide confidence intervals due to small sample size receive a minus () modifier. This system does not specifically address survey studies, which were therefore not assigned a level of evidence.

RESULTS

The screening process yielded 92 possible relevant articles, which were then reviewed individually (by G.M.M.) by title and abstract. A total of 81 articles were excluded, including 48 studies that were either noncomparative or descriptive in nature. Ten of the identified articles were reviews and did not contain primary data. Nine studies were not restricted to the pediatric population. Also excluded were 7 studies that did not have outcomes related to quality (eg, billing performance), and 7 studies of hospitalists in settings besides general pediatric wards (eg, pediatric intensive care units). Ten studies were thus identified. The cited reference tool was used to identify an additional article which met criteria, yielding 11 total articles that were included in the review.

Five of the identified studies published prior to 2005 were previously reviewed by Landrigan et al.9 Since then, 6 additional studies of similar nature have been published and were included here. Articles that met criteria but appeared in an earlier review are included in Table 1; new articles appear in Table 2. The results of all 11 articles were included for this discussion.

DISCUSSION

Of the 11 studies selected for this review, 10 measured length of stay as an outcome, with the majority favoring hospitalists but with mixed results. Three of these studies, those by Dwight et al.,12 Bellet and Whitaker,13 and Landrigan et al.,14 demonstrated 11% to 14% improvement for hospitalist services compared to community pediatricians. Boyd et al.,21 however, found exactly the opposite result, and 2 studies by Conway and Keren20 and Ogershok et al.16 found no difference in length of stay. Two more studies found benefits restricted to certain conditions: Wells et al.15 found 32% shorter lengths of stay for asthma, but not for other conditions; Srivastava et al.17 found a 13% reduction in length of stay for asthma and 11% for dehydration, but none for viral illnesses or when all conditions were combined. Bekmezian et al.18 found shorter lengths of stay on a hospitalist service for hematology and gastroenterology patients, and Simon et al.19 attribute a general trend of decreasing lengths of stay on a surgical service to the implementation of hospital comanagement for a small percentage of patients.

The most common quality measures studied were patient satisfaction, readmission rates, and mortality. Only 1 study by Ogershok et al.16 reported on patient satisfaction and found few differences between hospitalists and community pediatricians. Readmission rate were reported by 6 studies. Bellet and Whitaker13 found a higher readmission rate for pediatric hospitalists, Bekmezian et al.18 found a lower rate but on a subspecialty service. The study with the greatest power for this analysis, by Landrigan et al.14 with nearly 18,000 patients, found no difference, and neither did another 3 studies. Unsurprisingly, no study detected differences in mortality; it would be extremely difficult to adequately power a study to do so in the general pediatric setting, where mortality is rare.

The effect of relative experience of hospitalist physicians is uncertain. Boyd et al.21 speculated that 1 possible cause for the decreased lengths of stay and costs associated with their faculty group compared to hospitalists may have been due to the increased experience of the faculty group. Unfortunately, they were unable to generate statistical significance due to the small numbers of physicians in the study. In contrast, the hospitalists in the report by Dwight et al.12 had decreased lengths of stay but were less experienced. In the adult literature, the study by Meltzer et al.8 suggests that improved outcomes from hospitalist systems may not become apparent for 1 or more years after implementation, but none of the pediatric studies included in our review specifically address this issue. This leaves the possibility open that the hospitalist systems evaluated in some studies had insufficient time in which to develop increased efficiencies.

There were several limitations to our studies. First, due to the heterogeneity and methodological variations among the included studies, we were unable to perform a meta‐analysis. Second, the overall quality of evidence is limited due to the lack of randomized control trials. Third, a lack of agreement on appropriate quality markers has limited the study of quality of care. Published reports continue to focus on financial measures, such as length of stay, despite the recommendation in the previous review by Landrigan et al.9 that such studies would be of limited value. Finally, the current variability of hospitalist models and lack of study of factors that might influence outcomes makes comparisons difficult.

Despite these limitations, several interesting trends emerge from these studies. One such trend is that the more recent studies highlight that simple classification of hospitalist system versus traditional system fails to measure the complexity and nuance of care delivery. The 2006 study by Boyd et al.21 is especially notable because it showed the opposite effect of previous studies, namely, an increase in length of stay and costs for hospitalists at St Joseph's Medical Center in Phoenix, Arizona. In this study, the traditional faculty group was employed by the hospital, and the hospitalist group was a private practice model. The authors suggest that their faculty physicians were therefore operating like hospitalists in that almost all of their time was focused on inpatient care while they were on service. They also had a limited number of general pediatricians, who attended in the inpatient setting, who were more experienced than the private practice groups. Also, the authors theorize that their faculty may have had a closer working relationship with their residents due to additional service responsibilities and locations of the faculty group onsite. Further study of the care models utilized by faculty and hospitalist practices at St Joseph's and other hospitals may reveal important insights about improving the quality and efficiency of inpatient pediatric care in general.

Though there is a clear trend in the adult literature indicating that the use of hospitalists results in superior quality of care, there is less evidence for pediatric systems. The aforementioned previous review by Landrigan et al.9, in 2006 concluded that emerging research suggests that pediatric hospitalist systems decrease cost and length of stay, but also the quality of care in pediatric hospitalist systems is unclear, because rigorous metrics to evaluate quality are lacking. Data from the 6 additional studies presented here lend limited support to the first hypothesis, and the presence of only 1 negative study is not sufficient to undermine it.

While data on quality markers such as readmission rate or mortality remain elusive, the 2 studies by Conway et al.20, 22 attempt to evaluate quality by comparing the use of evidence‐based therapies by hospitalists and community pediatricians. Though the use of objective PHIS data for UTI in 2009 did not confirm the conclusion suggested by the 2006 provider survey study, the attempt to find measurable outcomes such as the use of evidence‐based therapies is a start but we need more metrics, including rigorous patient outcome metrics, to define the quality of our care systems. Before the effect of hospitalist systems on quality is fully understood, more work will need to be done defining metrics for comparison.

Unfortunately, over 5 years since the previous review by Landrigan et al.9 called for increased focus on inpatient quality and understanding how to improve, the sophistication of our measurement of pediatric inpatient quality and understanding of the mechanisms underlying improvement is still in its infancy. We propose a solution at multiple levels.

First, the investment in research comparing system‐level interventions (eg, discharge process A vs discharge process B) must be increased. This investment increased significantly due to the over $1 billion in Recovery Act funding for comparative effectiveness research.23 However, the future investment in comparative effectiveness research, often called patient‐centered outcomes research, and proportion of investment focused on delivery system interventions is unclear. We propose that the investment in comparing delivery system interventions is essential to improving not only hospital medicine systems, but, more importantly, the healthcare system broadly. In addition, research investment needs to focus on reliably implementing proven interventions in systems of care, and evaluating both the effects on patient outcomes and cost, and the contextual factors associated with successful implementation.24 A hospital medicine example would be the comparison of the implementation of a guideline for a common disease across a set of hospitals. One could perform a prospective observational design, in which one compares high intensity versus low intensity intervention and assesses the baseline characteristics of the hospital systems, to understand their association with successful implementation and, ultimately, patient outcomes. One could also perform a clustered randomized design.

Second, the development and implementation of pediatric quality of care measures, including in the inpatient setting, needs to increase rapidly. The Children's Health Insurance Program (CHIP) and its focus on an initial core set of quality measures that expands over time, through an investment in measure development and validation, is an opportunity for pediatric hospital medicine. Inpatient measures should be a focus of measure development and implementation. We must move beyond a limited set of inpatient measures to a broader set focused on issues such as patient safety, hospital‐acquired infections, outcomes for common illnesses, and transitions of care. We also need better measures for important pediatric populations, such as children with complex medical conditions.25

Third, our understanding of the mechanisms leading to improvement in hospital medicine systems needs to be developed. Studies of hospital medicine systems should move past simple binary comparisons of hospitalist systems versus traditional systems to understand the effect on patient outcomes and cost of factors such as years of experience, volume of patients seen overall and with a specific condition, staffing model, training, quality improvement knowledge and application, and health information systems. These factors may be additive or multiplicative to the performance of inpatient systems once put into place, but these hypotheses need to be tested.

Fourth, individual hospitalists and their groups must focus on quality measurement and improvement in quality and value delivered. At Cincinnati, we have a portfolio of quality and value projects derived from our strategic objectives, illustrated in Figure 2. The projects have leaders and teams to drive improvement and measure results. Increasingly, we are able to publish these results in peer‐reviewed journals. On a quarterly basis, we review the portfolio via a dashboard and/or run and control charts. We establish new projects and set new goals on at least an annual basis. It is important to note that at the beginning of the 2010‐2011 fiscal year, almost all initiatives identified as priorities were yellow or red. Our group is now planning new initiatives and goals for next year. This is one method applicable to our setting, but a focus on quality and value and measuring results needs to be part of every hospital medicine program. As payer focus on value increases, this will be essential to demonstrate how a hospitalist group improves outcomes and adds value.

Figure 2

CONCLUSION

This review suggests that the use of hospitalists can improve the quality of inpatient care in the pediatric population, but this is not a universal finding and, most importantly, the mechanisms of improvement are poorly understood. We propose 4 components to address these issues so that a systematic review 5 years from now would be much more robust. These are: 1) increased investment in research comparing system‐level interventions and reliable implementation; 2) further development and implementation of pediatric quality of care measures in the inpatient setting; 3) understanding the mechanisms and factors leading to improvement in hospital medicine systems; and 4) an increased focus on quality measurement, and improvement in quality and value delivered by all individual hospitalists and their groups.

In the United States, general medical inpatient care is increasingly provided by hospital‐based physicians, also called hospitalists.1 The field of pediatrics is no exception, and by 2005 there were an estimated 1000 pediatric hospitalists in the workforce.2 Current numbers are likely to be greater than 2500, as the need for pediatric hospitalists has grown considerably.

At the same time, the quality of care delivered by the United States health system has come under increased scrutiny. In 2001, the Institute of Medicine, in its report on the quality of healthcare in America, concluded that between the care we have and what we could have lies not just a gap but a chasm.3 Meanwhile, the cost of healthcare delivery continues to increase. The pressure to deliver cost‐effective, high quality care is among the more important forces driving the proliferation of hospitalists.4

Over the last decade, data supporting the role of hospitalists in improving quality of care for adult patients has continued to accumulate.58 A 2007 retrospective cohort study by Lindenaur et al.7 included nearly 77,000 adult patients and found small reductions in length of stay without adverse effects on mortality or readmission rates, and a 2009 systematic review by Peterson6 included 33 studies and concluded that in general inpatient care of general medical patients by hospitalist physicians leads to decreased hospital cost and length of stay. A 2002 study by Meltzer et al.8 is also interesting, suggesting that improvements in costs and short‐term mortality are related to the disease‐specific experience of hospitalists.

Similar data for pediatric hospitalists has been slower to emerge. A systematic review of the literature by Landrigan et al., which included studies through 2004, concluded that [R]esearch suggests that pediatric hospitalists decrease costs and length of stay . The quality of care in pediatric hospitalist systems is unclear, because rigorous metrics to evaluate quality are lacking.9 Since the publication of that review, there have been multiple studies which have sought to evaluate the quality of pediatric hospitalist systems. This review was undertaken to synthesize this new information, and to determine the effect of pediatric hospitalist systems on quality of care.

METHODS

A review of the available English language literature on the Medline database was undertaken in November of 2010 to answer the question, What are the differences in quality of care and outcomes of inpatient medical care provided by hospitalists versus non‐hospitalists in the pediatric population? Care metrics of interest were categorized according to the Society of Hospital Medicine's recommendations for measuring hospital performance.10

Search terms used (with additional medical subject headings [MeSH] terms in parenthesis) were hospital medicine (hospitalist), pediatrics (child health, child welfare), cost (cost and cost analysis), quality (quality indicators, healthcare), outcomes (outcome assessment, healthcare; outcomes and process assessment, healthcare); volume, patient satisfaction, length of stay, productivity (efficiency), provider satisfaction (attitude of health personnel, job satisfaction), mortality, and readmission rate (patient readmission). The citing articles search tool was used to identify other articles that potentially could meet criteria. Finally, references cited in the selected articles, as well as in excluded literature reviews, were searched for additional articles.

Articles were deemed eligible if they were published in a peer‐reviewed journal, if they had a comparative experimental design for hospitalists versus non‐hospitalists, and if they dealt exclusively with pediatric hospitalists. Noncomparative studies were excluded, as were studies that pertained to settings besides that of an inpatient pediatrics ward, such as pediatric intensive care units or emergency rooms. The search algorithm is diagrammed in Figure 1.

Figure 1

The selected articles were reviewed for the relevant outcome measures. The quality of each article was assessed using the Oxford Centre for Evidence‐Based Medicine levels of evidence,11 a widely accepted standard for critical analysis of studies. Levels of evidence are assigned to studies, from 1a (systematic reviews of randomized controlled trials) to 5 (expert opinion only). Well‐conducted prospective cohort studies receive a rating of 2c; those with wide confidence intervals due to small sample size receive a minus () modifier. This system does not specifically address survey studies, which were therefore not assigned a level of evidence.

RESULTS

The screening process yielded 92 possible relevant articles, which were then reviewed individually (by G.M.M.) by title and abstract. A total of 81 articles were excluded, including 48 studies that were either noncomparative or descriptive in nature. Ten of the identified articles were reviews and did not contain primary data. Nine studies were not restricted to the pediatric population. Also excluded were 7 studies that did not have outcomes related to quality (eg, billing performance), and 7 studies of hospitalists in settings besides general pediatric wards (eg, pediatric intensive care units). Ten studies were thus identified. The cited reference tool was used to identify an additional article which met criteria, yielding 11 total articles that were included in the review.

Five of the identified studies published prior to 2005 were previously reviewed by Landrigan et al.9 Since then, 6 additional studies of similar nature have been published and were included here. Articles that met criteria but appeared in an earlier review are included in Table 1; new articles appear in Table 2. The results of all 11 articles were included for this discussion.

DISCUSSION

Of the 11 studies selected for this review, 10 measured length of stay as an outcome, with the majority favoring hospitalists but with mixed results. Three of these studies, those by Dwight et al.,12 Bellet and Whitaker,13 and Landrigan et al.,14 demonstrated 11% to 14% improvement for hospitalist services compared to community pediatricians. Boyd et al.,21 however, found exactly the opposite result, and 2 studies by Conway and Keren20 and Ogershok et al.16 found no difference in length of stay. Two more studies found benefits restricted to certain conditions: Wells et al.15 found 32% shorter lengths of stay for asthma, but not for other conditions; Srivastava et al.17 found a 13% reduction in length of stay for asthma and 11% for dehydration, but none for viral illnesses or when all conditions were combined. Bekmezian et al.18 found shorter lengths of stay on a hospitalist service for hematology and gastroenterology patients, and Simon et al.19 attribute a general trend of decreasing lengths of stay on a surgical service to the implementation of hospital comanagement for a small percentage of patients.

The most common quality measures studied were patient satisfaction, readmission rates, and mortality. Only 1 study by Ogershok et al.16 reported on patient satisfaction and found few differences between hospitalists and community pediatricians. Readmission rate were reported by 6 studies. Bellet and Whitaker13 found a higher readmission rate for pediatric hospitalists, Bekmezian et al.18 found a lower rate but on a subspecialty service. The study with the greatest power for this analysis, by Landrigan et al.14 with nearly 18,000 patients, found no difference, and neither did another 3 studies. Unsurprisingly, no study detected differences in mortality; it would be extremely difficult to adequately power a study to do so in the general pediatric setting, where mortality is rare.

The effect of relative experience of hospitalist physicians is uncertain. Boyd et al.21 speculated that 1 possible cause for the decreased lengths of stay and costs associated with their faculty group compared to hospitalists may have been due to the increased experience of the faculty group. Unfortunately, they were unable to generate statistical significance due to the small numbers of physicians in the study. In contrast, the hospitalists in the report by Dwight et al.12 had decreased lengths of stay but were less experienced. In the adult literature, the study by Meltzer et al.8 suggests that improved outcomes from hospitalist systems may not become apparent for 1 or more years after implementation, but none of the pediatric studies included in our review specifically address this issue. This leaves the possibility open that the hospitalist systems evaluated in some studies had insufficient time in which to develop increased efficiencies.

There were several limitations to our studies. First, due to the heterogeneity and methodological variations among the included studies, we were unable to perform a meta‐analysis. Second, the overall quality of evidence is limited due to the lack of randomized control trials. Third, a lack of agreement on appropriate quality markers has limited the study of quality of care. Published reports continue to focus on financial measures, such as length of stay, despite the recommendation in the previous review by Landrigan et al.9 that such studies would be of limited value. Finally, the current variability of hospitalist models and lack of study of factors that might influence outcomes makes comparisons difficult.

Despite these limitations, several interesting trends emerge from these studies. One such trend is that the more recent studies highlight that simple classification of hospitalist system versus traditional system fails to measure the complexity and nuance of care delivery. The 2006 study by Boyd et al.21 is especially notable because it showed the opposite effect of previous studies, namely, an increase in length of stay and costs for hospitalists at St Joseph's Medical Center in Phoenix, Arizona. In this study, the traditional faculty group was employed by the hospital, and the hospitalist group was a private practice model. The authors suggest that their faculty physicians were therefore operating like hospitalists in that almost all of their time was focused on inpatient care while they were on service. They also had a limited number of general pediatricians, who attended in the inpatient setting, who were more experienced than the private practice groups. Also, the authors theorize that their faculty may have had a closer working relationship with their residents due to additional service responsibilities and locations of the faculty group onsite. Further study of the care models utilized by faculty and hospitalist practices at St Joseph's and other hospitals may reveal important insights about improving the quality and efficiency of inpatient pediatric care in general.

Though there is a clear trend in the adult literature indicating that the use of hospitalists results in superior quality of care, there is less evidence for pediatric systems. The aforementioned previous review by Landrigan et al.9, in 2006 concluded that emerging research suggests that pediatric hospitalist systems decrease cost and length of stay, but also the quality of care in pediatric hospitalist systems is unclear, because rigorous metrics to evaluate quality are lacking. Data from the 6 additional studies presented here lend limited support to the first hypothesis, and the presence of only 1 negative study is not sufficient to undermine it.

While data on quality markers such as readmission rate or mortality remain elusive, the 2 studies by Conway et al.20, 22 attempt to evaluate quality by comparing the use of evidence‐based therapies by hospitalists and community pediatricians. Though the use of objective PHIS data for UTI in 2009 did not confirm the conclusion suggested by the 2006 provider survey study, the attempt to find measurable outcomes such as the use of evidence‐based therapies is a start but we need more metrics, including rigorous patient outcome metrics, to define the quality of our care systems. Before the effect of hospitalist systems on quality is fully understood, more work will need to be done defining metrics for comparison.

Unfortunately, over 5 years since the previous review by Landrigan et al.9 called for increased focus on inpatient quality and understanding how to improve, the sophistication of our measurement of pediatric inpatient quality and understanding of the mechanisms underlying improvement is still in its infancy. We propose a solution at multiple levels.

First, the investment in research comparing system‐level interventions (eg, discharge process A vs discharge process B) must be increased. This investment increased significantly due to the over $1 billion in Recovery Act funding for comparative effectiveness research.23 However, the future investment in comparative effectiveness research, often called patient‐centered outcomes research, and proportion of investment focused on delivery system interventions is unclear. We propose that the investment in comparing delivery system interventions is essential to improving not only hospital medicine systems, but, more importantly, the healthcare system broadly. In addition, research investment needs to focus on reliably implementing proven interventions in systems of care, and evaluating both the effects on patient outcomes and cost, and the contextual factors associated with successful implementation.24 A hospital medicine example would be the comparison of the implementation of a guideline for a common disease across a set of hospitals. One could perform a prospective observational design, in which one compares high intensity versus low intensity intervention and assesses the baseline characteristics of the hospital systems, to understand their association with successful implementation and, ultimately, patient outcomes. One could also perform a clustered randomized design.

Second, the development and implementation of pediatric quality of care measures, including in the inpatient setting, needs to increase rapidly. The Children's Health Insurance Program (CHIP) and its focus on an initial core set of quality measures that expands over time, through an investment in measure development and validation, is an opportunity for pediatric hospital medicine. Inpatient measures should be a focus of measure development and implementation. We must move beyond a limited set of inpatient measures to a broader set focused on issues such as patient safety, hospital‐acquired infections, outcomes for common illnesses, and transitions of care. We also need better measures for important pediatric populations, such as children with complex medical conditions.25

Third, our understanding of the mechanisms leading to improvement in hospital medicine systems needs to be developed. Studies of hospital medicine systems should move past simple binary comparisons of hospitalist systems versus traditional systems to understand the effect on patient outcomes and cost of factors such as years of experience, volume of patients seen overall and with a specific condition, staffing model, training, quality improvement knowledge and application, and health information systems. These factors may be additive or multiplicative to the performance of inpatient systems once put into place, but these hypotheses need to be tested.

Fourth, individual hospitalists and their groups must focus on quality measurement and improvement in quality and value delivered. At Cincinnati, we have a portfolio of quality and value projects derived from our strategic objectives, illustrated in Figure 2. The projects have leaders and teams to drive improvement and measure results. Increasingly, we are able to publish these results in peer‐reviewed journals. On a quarterly basis, we review the portfolio via a dashboard and/or run and control charts. We establish new projects and set new goals on at least an annual basis. It is important to note that at the beginning of the 2010‐2011 fiscal year, almost all initiatives identified as priorities were yellow or red. Our group is now planning new initiatives and goals for next year. This is one method applicable to our setting, but a focus on quality and value and measuring results needs to be part of every hospital medicine program. As payer focus on value increases, this will be essential to demonstrate how a hospitalist group improves outcomes and adds value.

Figure 2

CONCLUSION

This review suggests that the use of hospitalists can improve the quality of inpatient care in the pediatric population, but this is not a universal finding and, most importantly, the mechanisms of improvement are poorly understood. We propose 4 components to address these issues so that a systematic review 5 years from now would be much more robust. These are: 1) increased investment in research comparing system‐level interventions and reliable implementation; 2) further development and implementation of pediatric quality of care measures in the inpatient setting; 3) understanding the mechanisms and factors leading to improvement in hospital medicine systems; and 4) an increased focus on quality measurement, and improvement in quality and value delivered by all individual hospitalists and their groups.

In the United States, general medical inpatient care is increasingly provided by hospital‐based physicians, also called hospitalists.1 The field of pediatrics is no exception, and by 2005 there were an estimated 1000 pediatric hospitalists in the workforce.2 Current numbers are likely to be greater than 2500, as the need for pediatric hospitalists has grown considerably.

At the same time, the quality of care delivered by the United States health system has come under increased scrutiny. In 2001, the Institute of Medicine, in its report on the quality of healthcare in America, concluded that between the care we have and what we could have lies not just a gap but a chasm.3 Meanwhile, the cost of healthcare delivery continues to increase. The pressure to deliver cost‐effective, high quality care is among the more important forces driving the proliferation of hospitalists.4

Over the last decade, data supporting the role of hospitalists in improving quality of care for adult patients has continued to accumulate.58 A 2007 retrospective cohort study by Lindenaur et al.7 included nearly 77,000 adult patients and found small reductions in length of stay without adverse effects on mortality or readmission rates, and a 2009 systematic review by Peterson6 included 33 studies and concluded that in general inpatient care of general medical patients by hospitalist physicians leads to decreased hospital cost and length of stay. A 2002 study by Meltzer et al.8 is also interesting, suggesting that improvements in costs and short‐term mortality are related to the disease‐specific experience of hospitalists.

Similar data for pediatric hospitalists has been slower to emerge. A systematic review of the literature by Landrigan et al., which included studies through 2004, concluded that [R]esearch suggests that pediatric hospitalists decrease costs and length of stay . The quality of care in pediatric hospitalist systems is unclear, because rigorous metrics to evaluate quality are lacking.9 Since the publication of that review, there have been multiple studies which have sought to evaluate the quality of pediatric hospitalist systems. This review was undertaken to synthesize this new information, and to determine the effect of pediatric hospitalist systems on quality of care.

METHODS

A review of the available English language literature on the Medline database was undertaken in November of 2010 to answer the question, What are the differences in quality of care and outcomes of inpatient medical care provided by hospitalists versus non‐hospitalists in the pediatric population? Care metrics of interest were categorized according to the Society of Hospital Medicine's recommendations for measuring hospital performance.10

Search terms used (with additional medical subject headings [MeSH] terms in parenthesis) were hospital medicine (hospitalist), pediatrics (child health, child welfare), cost (cost and cost analysis), quality (quality indicators, healthcare), outcomes (outcome assessment, healthcare; outcomes and process assessment, healthcare); volume, patient satisfaction, length of stay, productivity (efficiency), provider satisfaction (attitude of health personnel, job satisfaction), mortality, and readmission rate (patient readmission). The citing articles search tool was used to identify other articles that potentially could meet criteria. Finally, references cited in the selected articles, as well as in excluded literature reviews, were searched for additional articles.

Articles were deemed eligible if they were published in a peer‐reviewed journal, if they had a comparative experimental design for hospitalists versus non‐hospitalists, and if they dealt exclusively with pediatric hospitalists. Noncomparative studies were excluded, as were studies that pertained to settings besides that of an inpatient pediatrics ward, such as pediatric intensive care units or emergency rooms. The search algorithm is diagrammed in Figure 1.

Figure 1

The selected articles were reviewed for the relevant outcome measures. The quality of each article was assessed using the Oxford Centre for Evidence‐Based Medicine levels of evidence,11 a widely accepted standard for critical analysis of studies. Levels of evidence are assigned to studies, from 1a (systematic reviews of randomized controlled trials) to 5 (expert opinion only). Well‐conducted prospective cohort studies receive a rating of 2c; those with wide confidence intervals due to small sample size receive a minus () modifier. This system does not specifically address survey studies, which were therefore not assigned a level of evidence.

RESULTS

The screening process yielded 92 possible relevant articles, which were then reviewed individually (by G.M.M.) by title and abstract. A total of 81 articles were excluded, including 48 studies that were either noncomparative or descriptive in nature. Ten of the identified articles were reviews and did not contain primary data. Nine studies were not restricted to the pediatric population. Also excluded were 7 studies that did not have outcomes related to quality (eg, billing performance), and 7 studies of hospitalists in settings besides general pediatric wards (eg, pediatric intensive care units). Ten studies were thus identified. The cited reference tool was used to identify an additional article which met criteria, yielding 11 total articles that were included in the review.

Five of the identified studies published prior to 2005 were previously reviewed by Landrigan et al.9 Since then, 6 additional studies of similar nature have been published and were included here. Articles that met criteria but appeared in an earlier review are included in Table 1; new articles appear in Table 2. The results of all 11 articles were included for this discussion.

DISCUSSION

Of the 11 studies selected for this review, 10 measured length of stay as an outcome, with the majority favoring hospitalists but with mixed results. Three of these studies, those by Dwight et al.,12 Bellet and Whitaker,13 and Landrigan et al.,14 demonstrated 11% to 14% improvement for hospitalist services compared to community pediatricians. Boyd et al.,21 however, found exactly the opposite result, and 2 studies by Conway and Keren20 and Ogershok et al.16 found no difference in length of stay. Two more studies found benefits restricted to certain conditions: Wells et al.15 found 32% shorter lengths of stay for asthma, but not for other conditions; Srivastava et al.17 found a 13% reduction in length of stay for asthma and 11% for dehydration, but none for viral illnesses or when all conditions were combined. Bekmezian et al.18 found shorter lengths of stay on a hospitalist service for hematology and gastroenterology patients, and Simon et al.19 attribute a general trend of decreasing lengths of stay on a surgical service to the implementation of hospital comanagement for a small percentage of patients.

The most common quality measures studied were patient satisfaction, readmission rates, and mortality. Only 1 study by Ogershok et al.16 reported on patient satisfaction and found few differences between hospitalists and community pediatricians. Readmission rate were reported by 6 studies. Bellet and Whitaker13 found a higher readmission rate for pediatric hospitalists, Bekmezian et al.18 found a lower rate but on a subspecialty service. The study with the greatest power for this analysis, by Landrigan et al.14 with nearly 18,000 patients, found no difference, and neither did another 3 studies. Unsurprisingly, no study detected differences in mortality; it would be extremely difficult to adequately power a study to do so in the general pediatric setting, where mortality is rare.

The effect of relative experience of hospitalist physicians is uncertain. Boyd et al.21 speculated that 1 possible cause for the decreased lengths of stay and costs associated with their faculty group compared to hospitalists may have been due to the increased experience of the faculty group. Unfortunately, they were unable to generate statistical significance due to the small numbers of physicians in the study. In contrast, the hospitalists in the report by Dwight et al.12 had decreased lengths of stay but were less experienced. In the adult literature, the study by Meltzer et al.8 suggests that improved outcomes from hospitalist systems may not become apparent for 1 or more years after implementation, but none of the pediatric studies included in our review specifically address this issue. This leaves the possibility open that the hospitalist systems evaluated in some studies had insufficient time in which to develop increased efficiencies.

There were several limitations to our studies. First, due to the heterogeneity and methodological variations among the included studies, we were unable to perform a meta‐analysis. Second, the overall quality of evidence is limited due to the lack of randomized control trials. Third, a lack of agreement on appropriate quality markers has limited the study of quality of care. Published reports continue to focus on financial measures, such as length of stay, despite the recommendation in the previous review by Landrigan et al.9 that such studies would be of limited value. Finally, the current variability of hospitalist models and lack of study of factors that might influence outcomes makes comparisons difficult.

Despite these limitations, several interesting trends emerge from these studies. One such trend is that the more recent studies highlight that simple classification of hospitalist system versus traditional system fails to measure the complexity and nuance of care delivery. The 2006 study by Boyd et al.21 is especially notable because it showed the opposite effect of previous studies, namely, an increase in length of stay and costs for hospitalists at St Joseph's Medical Center in Phoenix, Arizona. In this study, the traditional faculty group was employed by the hospital, and the hospitalist group was a private practice model. The authors suggest that their faculty physicians were therefore operating like hospitalists in that almost all of their time was focused on inpatient care while they were on service. They also had a limited number of general pediatricians, who attended in the inpatient setting, who were more experienced than the private practice groups. Also, the authors theorize that their faculty may have had a closer working relationship with their residents due to additional service responsibilities and locations of the faculty group onsite. Further study of the care models utilized by faculty and hospitalist practices at St Joseph's and other hospitals may reveal important insights about improving the quality and efficiency of inpatient pediatric care in general.

Though there is a clear trend in the adult literature indicating that the use of hospitalists results in superior quality of care, there is less evidence for pediatric systems. The aforementioned previous review by Landrigan et al.9, in 2006 concluded that emerging research suggests that pediatric hospitalist systems decrease cost and length of stay, but also the quality of care in pediatric hospitalist systems is unclear, because rigorous metrics to evaluate quality are lacking. Data from the 6 additional studies presented here lend limited support to the first hypothesis, and the presence of only 1 negative study is not sufficient to undermine it.

While data on quality markers such as readmission rate or mortality remain elusive, the 2 studies by Conway et al.20, 22 attempt to evaluate quality by comparing the use of evidence‐based therapies by hospitalists and community pediatricians. Though the use of objective PHIS data for UTI in 2009 did not confirm the conclusion suggested by the 2006 provider survey study, the attempt to find measurable outcomes such as the use of evidence‐based therapies is a start but we need more metrics, including rigorous patient outcome metrics, to define the quality of our care systems. Before the effect of hospitalist systems on quality is fully understood, more work will need to be done defining metrics for comparison.

Unfortunately, over 5 years since the previous review by Landrigan et al.9 called for increased focus on inpatient quality and understanding how to improve, the sophistication of our measurement of pediatric inpatient quality and understanding of the mechanisms underlying improvement is still in its infancy. We propose a solution at multiple levels.

First, the investment in research comparing system‐level interventions (eg, discharge process A vs discharge process B) must be increased. This investment increased significantly due to the over $1 billion in Recovery Act funding for comparative effectiveness research.23 However, the future investment in comparative effectiveness research, often called patient‐centered outcomes research, and proportion of investment focused on delivery system interventions is unclear. We propose that the investment in comparing delivery system interventions is essential to improving not only hospital medicine systems, but, more importantly, the healthcare system broadly. In addition, research investment needs to focus on reliably implementing proven interventions in systems of care, and evaluating both the effects on patient outcomes and cost, and the contextual factors associated with successful implementation.24 A hospital medicine example would be the comparison of the implementation of a guideline for a common disease across a set of hospitals. One could perform a prospective observational design, in which one compares high intensity versus low intensity intervention and assesses the baseline characteristics of the hospital systems, to understand their association with successful implementation and, ultimately, patient outcomes. One could also perform a clustered randomized design.

Second, the development and implementation of pediatric quality of care measures, including in the inpatient setting, needs to increase rapidly. The Children's Health Insurance Program (CHIP) and its focus on an initial core set of quality measures that expands over time, through an investment in measure development and validation, is an opportunity for pediatric hospital medicine. Inpatient measures should be a focus of measure development and implementation. We must move beyond a limited set of inpatient measures to a broader set focused on issues such as patient safety, hospital‐acquired infections, outcomes for common illnesses, and transitions of care. We also need better measures for important pediatric populations, such as children with complex medical conditions.25

Third, our understanding of the mechanisms leading to improvement in hospital medicine systems needs to be developed. Studies of hospital medicine systems should move past simple binary comparisons of hospitalist systems versus traditional systems to understand the effect on patient outcomes and cost of factors such as years of experience, volume of patients seen overall and with a specific condition, staffing model, training, quality improvement knowledge and application, and health information systems. These factors may be additive or multiplicative to the performance of inpatient systems once put into place, but these hypotheses need to be tested.

Fourth, individual hospitalists and their groups must focus on quality measurement and improvement in quality and value delivered. At Cincinnati, we have a portfolio of quality and value projects derived from our strategic objectives, illustrated in Figure 2. The projects have leaders and teams to drive improvement and measure results. Increasingly, we are able to publish these results in peer‐reviewed journals. On a quarterly basis, we review the portfolio via a dashboard and/or run and control charts. We establish new projects and set new goals on at least an annual basis. It is important to note that at the beginning of the 2010‐2011 fiscal year, almost all initiatives identified as priorities were yellow or red. Our group is now planning new initiatives and goals for next year. This is one method applicable to our setting, but a focus on quality and value and measuring results needs to be part of every hospital medicine program. As payer focus on value increases, this will be essential to demonstrate how a hospitalist group improves outcomes and adds value.

Figure 2

CONCLUSION

This review suggests that the use of hospitalists can improve the quality of inpatient care in the pediatric population, but this is not a universal finding and, most importantly, the mechanisms of improvement are poorly understood. We propose 4 components to address these issues so that a systematic review 5 years from now would be much more robust. These are: 1) increased investment in research comparing system‐level interventions and reliable implementation; 2) further development and implementation of pediatric quality of care measures in the inpatient setting; 3) understanding the mechanisms and factors leading to improvement in hospital medicine systems; and 4) an increased focus on quality measurement, and improvement in quality and value delivered by all individual hospitalists and their groups.